Guest: Dr. Richard LiptonPresenter: Neal HowardGuest Bio: Richard B. Lipton, M.D., is the Edwin S. Lowe Professor and Vice Chair of Neurology, Professor of Epidemiology and Population Health and Professor of Psychiatry and Behavioral Sciences at the Albert Einstein College of Medicine. His research focuses on cognitive aging, Alzheimer’s disease and migraine headaches as co-Director of the Montefiore Headache Center, an interdisciplinary subspecialty center focused on headache, patient care, research and education.
Dr. Lipton holds leadership positions in several professional societies. He is a Past-President of the American Headache Society (AHS). He serves on the editorial boards of several journals, including Neurology. He has written 11 books. Dr. Lipton enjoys mentoring medical students, residents, PhD students and fellows. Over the last decade he has mentored 7 CRTP students and 6 K-award recipients. He has received both the CRTP Mentor of the Year Award and the Einstein Faculty Mentoring Award.
Dr. Richard Lipton was a speaker at the inaugural Migraine World Summit in 2016.

Neal Howard: Hello and welcome to the program today. I’m your host Neal Howard and you’re listening to Health Professional Radio, happy that could join us. Our guest in studio today is returning with us Dr. Richard Lipton, Vice Chair of Neurology, Professor of Epidemiology and Population Health Director of Montefiore Headache Center. And he’s here in studio today with us to talk about the subspecialty in neurology of headache medicine. Welcome to the program Doctor.

Dr. Richard Lipton: Thank you so much.

N: Now let’s talk first about the Montefiore Headache Center. Where exactly is it located?

L: Yes, so the Montefiore Headache Center is located in the North Bronx immediately adjacent to the Albert Einstein College of Medicine. So the health care delivery system I work for is Montefiore and then the medical school I work for is Albert Einstein and they’re very closely affiliated in the North Bronx.

N: Does it focus on migraine or does it focus on any type of headache even those that are caused by maybe sports injuries or traumatic brain injuries due to collisions in sports?

L: Yes. So the Headache Center broadly focuses on pain in the head and then in the neck and then the face. Far and away the most common disorder we treated is either is some form of migraine either in its episodic or chronic variants but we treat a variety of headache disorders including traumatic and post-traumatic headache and cluster headache, trigeminal autonomic cephalalgias, trigeminal neuralgias. We treat a range of disorders that probably 60% of the patients have some form of migraine.

N: What would you say is your, I guess your flagship treatment, the treatment that you find yourself administering the most often at the center?

L: Well so it really depends on the headaches disorder but for chronic migraine which is the most common disorder that we treat, the single breakthrough that’s made the biggest difference in management has been the FDA approval of OnabotulinumtoxinA or Botox as a preventive treatment for chronic migraine. So that’s been an FDA approved treatment for several years now and the results in people with refractory migraine have been really excellent for a number of people though unfortunately it’s not a treatment that works for absolutely everyone and we’re not so good at predicting which people with chronic migraine it will most benefit but when it works it can be a life changing therapy.

N: You’re talking about Botox, are we talking about injecting it under the skin or does the Botox get injected into a vein, is there some different type of method of using the Botox, is it actually an injectable or an ingestible?

L: No, no, no. So Botox is a protein so if you take it by mouth it’s not absorbed, so Botox is given by injection and in fact Botox treatment for chronic migraine was discovered when people were getting cosmetic Botox into their foreheads and their headaches got better and after a lot of experimentation, a very specific protocol was developed called the pre-em protocol which involves injecting a small amount of Botox using very small needles into 31 sites at the front of the head, the back of the head and the neck and those injections are given once every 3 months usually and that treatment protocol which has proven efficacy for chronic migraine that’s used most often by headache specialists.

N: Now are these, I guess every 2 or 3 months treatments for all of these 30 plus locations in the front of the head, the back of the neck and the back of the head or specific locations out of these 30 plus based on the patient?

L: Yes. So in the beginning the treatment strategy that was used was called following the pain, so if somebody had a right frontal headache the Botox was given primarily in right frontal regions but we learned over time that giving a widely distributed injection protocol actually was the most effective treatment and so the way Botox was used in practice is that everyone gets 31 injections and then some people may get extra Botox in areas where there’s pain though it’s not a hundred percent clear that giving that extra Botox following the pain makes a difference, it is clear that giving injections at the 31 sites that the protocol specifies is a very effective treatment.

N: Talk about some of the other neurological conditions that are associated with migraine headache and some of them that maybe are caused by migraine headaches.

L: Sure. So migraine has a large number of neurologic, psychiatric and medical co-morbidities. So the definition of, we say two conditions are co-morbid if they occurred together with a greater frequency than we would expect by chance alone. So migraine is co-morbid with epilepsy, people with epilepsy are twice as likely to have migraine. People with migraine are twice as likely to have epilepsy and that make sense because both migraine and epilepsy are disorders of enhanced brain excitability, some of the genes that contribute to migraine also contribute to epilepsy so there is some shared neurobiological basis as well. Migraine with aura in particular occurs with elevated frequency in patients who have multiple sclerosis and that’s been studied in primarily in multiple sclerosis centers. Migraine is co-morbid with stroke and that co-morbidity is almost certainly confined to people who have migraine with aura who were twice as likely to have stroke or transient ischemic attacks. Migraine to some degree is associated with some other rare neurologic disorders where there may be a shared genetic underpinning, one example might be episodic ataxia. Migraine’s also co-morbid with a huge variety of pain disorders, so migraine occurs with increased frequency in people with fibromyalgia, temporomandibular joint disorder, painful neuropathy, irritable bowel syndrome…so virtually any pain disorder, osteoarthritis, back pain, virtually any pain disorder you name is a fellow traveler with migraine. So those are the common neurologic co-morbidities, so another one is restless leg syndrome and that one is not well understood but well documented in population studies.

N: How often are migraines brought on purely by genetics and are they ever brought on by an injury?

L: Right, so it’s a good question. We know from twin studies that about half the risk of having migraine is determined by genetic factors but the other half presumed with determined by environmental factors. So if a condition was purely genetic, you would expect that identical twins would be a hundred percent concordance so whether or not they have migraine that they’re actually only perhaps 60% concordant so whether they have migraine. So non-genetic factors play an important role and one way of thinking about it is that the genes determine predisposition, the environment determines whether that predisposition is expressed and there’s no question that head injury is associated with migraine like headache, so for example among veterans of the Iraq war who experienced blast injury, migraine like headaches occur at very high rates. Similarly we know that some of the medicines that are used to relieve headache or other kinds of pain can make headache worst if those medicines are used on a long term basis and the drugs most likely to do that are opioid, analgesic or Butalbital containing combination of ingredient products like Fiorinal or Fioricet. So we know if we go into an arthritis clinic and look at people who are taking pain killers for arthritis some group of them will develop chronic migraine and presumably what we’re seeing is that the genetic predisposition is enhanced in its expression through the overuse of analgesics and the same thing can happen with traumatic brain injuries. You have a predisposition, you get a head injury, you might have a short-term headache and it’s quickly relieved. If you’re genetically predisposed to migraine and you get a head injury that may lead to a headache that occurs over months or even years of your life. So it’s what I would call a genetic diaphysis superimposed environmental stress model that helps us understand who gets migraine, how bad it is and how long it lasts.

N: Now in wrapping up Doctor, talk about headache in children. How young do you offer your services?

L: Yes. So we have child neurologists in our department who treat kids very early in life. Interestingly there’s evidence that even among that colic in infants may be a form of migraine and the evidences that kids with colic grow up to have migraine at increased rates in kids with colic are more likely to have parents with migraine than kids free of colic. So when babies cry excessively that may be a very early childhood form of migraine certainly by the time kids are 4 or 5 there’s clear evidence of migraine. Interestingly below the age of 12 migraine is more common in little boys than in little girls that but the age of menarche when young women begin having their periods, the risk of migraine dramatically increases in females suggesting that cyclical hormonal factors may be a kind of environmental risk factor that enhances the expression of migraine and interestingly during the menopausal transition headaches my get worst. After menopause headaches may improve and again that supports the existence of important hormonal length.

N: Doctor, it’s been a pleasure having you here with us today.

L: Pleasure was mine. Thank you so much.

N: You’ve been listening to Health Professional Radio, I’m your host Neal Howard. And we’ve been in studio today with Dr. Richard Lipton, he’s Vice Chair of Neurology, Professor of Epidemiology and Population Health Director of Montefiore Headache Center. And he’s been discussing the subspecialty of headache medicine and the services offered at the Headache Center. You can get transcripts and audio of this program at healthprofessionalradio.com.au and also at hpr.fm and you can subscribe to this podcast on iTunes.

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